Informed Consent Form
(Consent to Treatment)

Welcome to the practice! I look forward to our work together as you seek to make positive, healthy changes in your life. I want to make our experience together as comfortable and productive as possible. Therefore, in an effort to provide you with important information about our work together, and to promote a trusting and well-informed relationship, this Informed Consent Form outlines crucial elements of our experience as well as information about my professional services and business policies. Please read it carefully and make note of any questions you might have so that we can discuss them together before signing. By signing below, you are agreeing to all the terms of this Informed Consent Form.

Consent & Waiver

You voluntarily desire to participate in the services provided by Amy Denicke DC, LLC (the “Practitioner”) and other practitioners or practices in partnership with Amy Denicke DC, LLC. In exchange for participation in these services and/or use of the property, facilities, and services, you consent to the following:

About Me: As the Practitioner, I am holding myself out and practicing as a Chiropractor. My highest educational degree is a Doctor of chiropractic medicine. I am also a certified functional medicine professional with Institute for Functional Medicine and Functional Medicine University. I am licensed to provide services within my scope of chiropractic practice in the state of Colorado. If you have any questions about my education, training or experience before you start receiving my services, please do not hesitate to ask.

Services: My Services include the following:

● 20-Minute Discovery Consultation during which you and I will make an initial determination about whether or not we believe my services are a good fit for you.

● If we decide to proceed from there, we may hold a 60-90-Minute Initial Consultation depending on which avenue of care is decided upon.

● After that, I may recommend, and you may choose to receive, any of my Services or Follow Up appointments, depending on my assessment of your needs. My Services may consist of lab testing with interpretations, personalized protocols, nutritional recommendations, virtual one on one visits, including Follow Up Appointments, online programs and/or memberships. Follow Up Appointments are approximately 30-45 minutes in length. Within the membership level, quick questions or subject inquiries that require less than a collective 20 minutes of time can be handled at no additional fee on the practice portal.

Throughout our work together and the delivery of the Services, I will offer a variety of professional recommendations that will likely include facilitation of self-awareness, encouragement of new insights, experimentation with new behaviors, and new ways of looking at yourself and your health. Change usually involves letting go of things that are familiar in order to make room for new possibilities to emerge. Also, changes that you make in one area of your life may induce changes in other areas such as your relationships with others. All in all, you understand that there are no guarantees of what you will experience, the results you will achieve, or how you will feel during and after working together.

Your health care provider has authorized functional, nutritional, and lifestyle evaluation, testing, consulting, and care, including dietary supplements. You understand and are informed that products and services are not provided by medical physicians and do not include prescription of legend drugs, surgery, or other conventional allopathic medical treatments. You further understand that consultations, evaluations, supplementation, lifestyle consultation, testing, recommendations, discussion, sale of food, nutrition, nutritional supplements, vitamins or minerals, food grade herbs, or other nutrients pertain to the functional health/whole body concept.

Voluntary Participation & Informed Consent.

FUNCTIONAL HEALTH/FUNCTIONAL MEDICINE: Doctor of Chiropractic practicing in a functional health/functional medicine model view health as a continuum from optimal health to hidden imbalances to disease. Rather than treating disease (e.g. cancer, hypothyroid, or multiple sclerosis), we address underlying neurologic, metabolic, physiologic, and functional imbalances, intervening at the root cause. One effect may be the ability to reduce or eliminate the need for medications, which must be done by your prescribing provider. As Doctors of Chiropractic, we do not prescribe drugs or perform surgery. Therefore, all changes to prescription medications must be made by your prescribing provider.

ALTERNATIVES: Alternatives include doing nothing, relying solely on drug therapy, or consulting with other providers. Chiropractic is a branch of the healing arts distinct from other branches (e.g. nursing, osteopathic, or allopathic). I understand that the doctors in this practice are Doctors of Chiropractic who have post graduate education in functional endocrinology and clinical nutrition, and that diagnosing and treating human diseases or ailments is within the scope of chiropractic practice. Nonetheless, we encourage you to communicate with your other health providers about the care you receive.

RISKS: You understand the nutritional supplements, vitamins, minerals, food grade herbs, and other nutrients that may be recommended are generally considered safe, however, some nutritional supplements, vitamins, minerals, food grade herbs, and other nutrients may be toxic in certain doses. You also understand that nutritional supplements, vitamins, minerals, food grade herbs, and other nutrients may interact with some legend drugs. Accordingly, you agree to consult with you prescribing physician about any legend drugs that you are taking and the impact of supplements, vitamins, minerals, food grade herbs, and other nutrients on such drugs. You will inform your prescribing physician if you experience gastrointestinal upset (nausea, gas, stomachache, vomiting), allergic reactions (hives, rashes, itching, tingling of the tongue, headache), or any unanticipated or unpleasant effects associated with the nutritional supplements, vitamins, minerals, food grade herbs, and other nutrients.

NOT EVALUATED BY THE FDA: The information contained on this Website or provided through our Website, Programs, Products, Product recommendations, and Services have not been evaluated by the Food and Drug Administration.

REFERRAL FOR BHRT and/or MEDICATION: There are times when test results and educated reasoning may deem a medication or bio-identical hormone replacement therapy serves as an integrative or triaged recommendation to improve clinical outcomes of care sought after in our office. The prescribing of any medication is out of chiropractic scope of practice so you will be referred to an appropriately licensed practitioner that will analyze test results and may suggest a particular medication or hormone if they find appropriate and appropriate within their scope of practice. There is no affiliation or liability with the referring practitioner to the practice or Dr. Amy Denicke and all responsibility and outcomes of any medication or hormone replacement recommended falls outside of the care plan or protocol associated with our office, doctors, and wellness partners.

SPECIALTY LAB TESTING: The purpose of functional medicine laboratory testing in our practice is to evaluate nutritional, biochemical, or physiological imbalances and to determine need for medical referral. These lab tests in our office are not intended to diagnose disease(s). This office utilizes conventional lab tests, as well as other labs used commonly in a functional medicine setting. Functional medicine specific testing and assessments are designed to assist our doctors and other healthcare providers in finding the underlying causes of your condition and nervous system imbalances. Functional medicine has evolved through the efforts of scientists and clinicians from the fields of clinical nutrition, molecular biology, biochemistry, physiology, conventional medicine, and a wide array of scientific disciplines. Functional medicine evaluates the body as a whole, with special attention to the relationship of one body system to another and the nutrient imbalances and toxic overload that may adversely affect these relationships. Other healthcare providers may or may not agree with the necessity for—or our interpretation of—these tests. If you have any questions or concerns, please discuss them with us or your doctor(s).

PREGNANCY: You understand that some nutritional supplements, vitamins, minerals, food grade herbs, and other nutrients may be inappropriate or contraindicated during pregnancy, and you will notify the health practitioner and your prescribing physician if you are pregnant or become pregnant.

RISKS: Nutritional remedial measures and supplements used in our practice are generally considered safe; however, they may involve some risks including, without limit, changes in blood sugar or gastrointestinal upset. They may also interact with certain drugs and may be inappropriate during pregnancy. Chiropractic adjustment involves some risks including, without limit, fractures, disc injuries, dislocations, and sprains. Additionally, hidden conditions may exist that are not detectable through x-ray or physical or neurological exams. This may include spinal tumors, weak or occluded arteries, and aneurysms. Accordingly, there are some people that are at risk for stroke or vascular injuries.

The methods of nutritional evaluation or testing made available to you are not intended to diagnose disease from an allopathic medicine viewpoint. Rather, they are intended as a guide to developing an appropriate overall nervous system and health-supportive program for you, and to monitor progress in achieving your health goals. You further understand that any recommendations are supportive in nature allowing the nervous system to return to improved health. Like all other health care, results are not guaranteed and there is no intentions to cure anything.

PAYMENT, INSURANCE, AND REFUNDS: Payment for services is not conditional on response to care. There is no guarantee of insurance coverage. Often, you will not know if an insurer will cover any costs until you send an invoice. Any insurance you have is an agreement between you and your insurance carrier and you are responsible for payment of services, whether they are covered by insurance or not. No refunds are available, in full or in part, for any Consultations, Appointments or Services that already have been held or completed. Prorated fees for unused, prepaid membership services (Core Intensive and Flex Memberships) will be refunded within the first 30 days if you wish to cancel, however, no refunds are available for any product purchases. Prorated fees for unused, prepaid services included in our online programs are not refundable if the program holder wants to cancel at any time. No refunds are available for any product purchases at any time that does not adhere to Full Script's return policy. Any returns of products must be handled by the program holder/member and Full Script separately. Payment for goods and/or Services must be paid at the time of service rendered and/or good(s) sold.

NO GUARANTEE: Every individual responds to care differently and no guarantee or assurance is made as to the results of care in any specific case, as care may not improve your condition or result in reducing medications. We can, however, speak of our experience treating functional and nervous system imbalances, and the success seen in our office has been excellent. Success includes documented subjective or objective functional improvement.

The Consultations, Services and Appointments that you may receive have both benefits and risks, and it is important that you are aware of both the benefits and the risks. For instance, application of recommendations may result in reduction in feelings of distress, stress, worry or fear, and may result in positive behavioral changes, greater happiness, more satisfying relationships, greater physical health, etc. At the same time, since our work together often involves discussing aspects of your health and wellness that you are currently struggling with, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and/or helplessness in the process as you share and shift these feelings.

You acknowledge that you are choosing to participate voluntarily in the Services and you recognize that they may contain certain inherent risks. You have discussed the potential benefits and possible side effects of Services with me and your primary physician, and you agree that you assume the risks of receiving Services. You have had an opportunity to ask questions and you agree to assume all risks during the Services in which you participate. You agree to take responsibility for your life and well-being and all decisions made before, during and after the Services are rendered.

You also understand and agree to disclose any and all medications and supplements that you are taking, recognizing that failing to disclose them could cause potential negative reactions or unanticipated and harmful drug interactions if you implement certain recommendations that I might offer.

You agree to disclose information requested from you about your health, wellness, medications, supplements, and other health conditions that we deem could impact our recommendations, treatment, and your health. You are affirming that you have stated all known medical conditions and answered all questions honestly and you agree to provide complete and accurate health information and notice of health changes at successive Appointments. If you suspect that you have a medical or mental health emergency, issue or concern, you agree to inform us or report to your physician and/or emergency room if appropriate.

Scheduling & Appointments.

Scheduling With Me: Appointments are scheduled through my confidential online portal called Practice Better and can be accessed online through my website. Please come prepared to start and end your Appointments on time and fill out all requested digital forms beforehand. Special scheduling requests can be made through email or on the portal's message board.

Rescheduling: If you need to reschedule an Appointment, you need to do so at least 24 hours in advance of your scheduled time by changing it on the online portal.

Cancelled & Missed Appointments: Our time together is important. If you need to cancel your Appointment, you need to do so at least 24 hours in advance of your scheduled time by sending an e-mail to me or doing it through the online portal. If you do not contact me at least 24 hours in advance, this will be considered a missed Appointment. If you miss or cancel a scheduled Appointment, you may be charged a Cancellation Fee of $50 unless you notify me at least 24 hours in advance by e-mail at support@coreflexwellness.com or request one through the online portal.

Late Appointments: If you arrive late for your Appointment, it may need to end at the scheduled time frame, and no additional time will be added to the end of your scheduled Appointment. Should you arrive late, you will still need to pay the full fee for the full Appointment, even though you may only be seen for a portion of the Appointment as you will have forfeited the time you missed due to being late.

Fees and Payment. Fees for my Services are as follows:

Initial Consultation: 60-90 minutes - $399

Follow Up Appointment: 30 minutes - $150

Programs and memberships are inclusive of time and varies with program or membership inclusions.

Payment: Payment may be made in person or upon receipt of an invoice. Payment may be made by check, digital currency such as PayPal or Apple Pay, or credit/debit card. For the Initial Consultation, Follow-Up Appointments and Other single fee Services, payment is due and payable by or at the receipt of Services. Please note that chargebacks are not permitted and that by signing below, you are agreeing that you will make payment in full or in various installments if agreed upon. Programs that include various tests, supplement recommendations, and discounts are paid for in full or in partial payments as offered in certain programs enabled in the online payment pages.

Insurance: At this time, I am/am not a member of any managed care/insurance provider panels or plans. Depending on insurance policy out of network benefits, you may qualify for some reimbursement on specialty testing. Blood testing through me is not covered in network. Cooperation through your medical providers to access insurance benefits for testing may be an option and can be discussed further and once under care or enrolled in a program or membership.

Late Payments & Non-Payment: If a payment is more than 3 days late past the due date on the invoice, you may be assessed a Late Fee of $25 in addition to the amount of the invoice unless a written or electronic agreement has been identified for payment of fees. If your invoice has not been paid for more than 60 days and arrangements for payment have not been agreed upon, you agree in advance that I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, you will be billed additional charges to cover the cost of time and expenses incurred by me in obtaining payment, including legal fees, and these costs will be included in the claim. In the case of collections, typically the information that is released to the bill collector is the client’s name, the nature of services provided, and the amount due. I hope I would not need to resort to collections to secure payment, but should that be the case, you are consenting to the release of this, and any other relevant information should collections efforts become necessary.

Confidentiality & Disclosure. You consent to the use and disclosure of your identifiable health information and personal data for the purposes related to your Services. You understand that under HIPAA (the Health Insurance Portability and Accountability Act) and, if applicable, the General Data Protection Regulation (GDPR), you have the right to request restrictions as to how your identifiable health information is used or disclosed to others. Your identifiable health information includes health information as well as your demographic information that is collected from us and/or created or received by us, another health care provider, a health plan, your employer or a health care clearinghouse. It will be used to create recommendations, protocols and other suggestions based on your needs. This identifiable health information relates to your past, present or future physical or mental health or condition and identifies you, or there is reasonable basis to believe the information may identify you.

You understand that you have the right to:

● Request a copy of your health records

● Request a correction of information that you deem incorrect in your health records

● Request that your health information not be shared with certain individuals

● Request that your health information not be used for certain purposes (e.g., research)

● Request us to send copies of your health records to whomever you wish

● Be informed as to who has read your records (for reasons other than treatment or payment)

● Specify how and where we may contact you

● Receive a copy of a full HIPAA Notice of Privacy Practices upon request

In general, the privacy of our communication is protected by law, and I can only release information about our work to others with your written permission; however, there are some situations in which I may be legally obligated to reveal some information about you, even without your consent. You understand that your confidential health information will not be disclosed anyone else without your written consent prior to access or disclosure, except in the situations outlined below or as allowable under HIPAA, including:

● If in my professional judgment I believe you lack the capacity or refuse to care for yourself, and such lack of self-care presents substantial threat to your well-being or the well-being of others.

● If you threaten serious bodily harm or death to yourself.

● If you threaten serious bodily harm or death to another.

● If the abuse, neglect, or exploitation of a child, elder adult, or dependent adult is suspected.

● If you are involved in a legal proceeding and a judge issues a court order for your testimony.

● If you pursue civil or criminal legal action against me or if you make a complaint to a Professional Board about me.

● If release of information is otherwise required by law (e.g. reporting of medical errors, due to a court order or subpoena, requested under the Patriot Act).

In addition, you should be aware of the following limits to confidentiality, and you consent to disclosure under these circumstances:

● I may find it helpful or required to consult with other medical or mental health care professionals for the purpose of gaining professional supervision, support, education, and exchange of ideas. During such consultations, I make every effort to avoid revealing your identity. The consultant in these instances will be a medical or mental health care professional who is therefore also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important.

● Information that you allow me to exchange with other professionals or information that you might choose to provide via email, fax, or cell phone cannot be guaranteed confidential.

● Although rare and unexpected, it is possible that confidential information stored on my computer and protected by passwords and accessible legally only by me could be accessed illegally by others.

Minors and Parents (if applicable).

Patients under the age of 18 and their parents should be aware that the law may provide parents with the right to examine their child’s medical records. I understand that as a parent, you are concerned about your child and therefore may want to know the content of your child’s conversations with me. Before giving you as the parent any information about your child, I will discuss the matter with the minor, if possible, and do my best to handle any objections he/she may have with what I plan to discuss with you. Both the child and the parents must signify that you agree to this policy by signing below.

Termination of Relationship.

You have the right to discontinue your Services solely within my practice at any time. If you or I determine that you are not benefiting or that it is no longer a good fit for either of us, either if us may elect to discontinue our work together if either of us believe that it is not in the best interest of your health or wellness. We agree to do our best to provide at least 14 days advance notice to the other via e-mail for you at the e-mail address you provide below and for me at my e-mail address dramy@coreflexwellness.com should we wish to terminate our work together.

Limitation of Liability & Release of Claims.

You waive and release the Practitioner from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which you may have or claim to have in the future against the Practitioner arising from your past or future participation in, or otherwise with respect to, anything related to and including the Services, to the fullest extent permissible by law. You agree to pay for all damages to any person and the facilities caused by any negligent, reckless, or willful action that you may take that may arise while receiving the Services or you are under the care of the Practitioner.

Signature(s).

You understand that by signing this Informed Consent Form, you acknowledge that it will apply to all current and future Services you receive. Your signature below indicates that you are at least a legal age of 18 to give consent, you have carefully read this Informed Consent Form, and you have had the opportunity to ask questions and address your concerns before signing it. By signing below, you agree that you voluntarily request and consent to our Services and our work together, and you understand and have been informed of the potential risks and you are voluntarily and knowingly assuming these risks. You understand that by signing below you are voluntarily surrendering certain legal rights. Your signature also indicates that you understand and provide your informed consent to the issues related to the risks and benefits of the Services, and my policies related to confidentiality, fees and payment, and all other responsibilities and terms of this Agreement.

You understand that by agreeing to this Informed Consent form, you acknowledge that it will apply to all current and future Services that you receive. Your acknowledgement below indicates that you are at least a legal age of 18 to give consent, you have carefully read this Informed Consent Form, and you have had the opportunity to ask questions and address your concerns before agreeing to it.

By checking the box below, you agree that you voluntarily request and consent to our Services and our work together, and you understand and have been informed of the potential risks and you are voluntarily and knowingly assuming these risks. You understand that you are voluntarily surrendering certain legal rights. Your agreement also indicates that you understand and provide your informed consent to the issues related to the risks and benefits of the Services, and my policies related to confidentiality, fees and payment, and all other responsibilities and terms of this Agreement.

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